Enteropathic arthritis
Enteropathic arthritis is the spondyloarthritis that accompanies Crohn disease or ulcerative colitis, splitting into peripheral arthritis that tracks bowel activity and axial sacroiliitis or spondylitis that runs independently and is human leukocyte antigen B27-associated. Peripheral disease is managed by controlling the bowel; persistent or axial disease escalates to a tumor necrosis factor inhibitor such as infliximab, since NSAIDs relieve the joints but can flare the bowel.
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What this article covers
- Overview
Definition: enteropathic arthritis is the spondyloarthritis that develops with inflammatory bowel disease (IBD), Crohn disease or ulcerative colitis, splitting into a peripheral form and an axial…
- Epidemiology
Spondyloarthritis is the most common extra-articular manifestation of IBD; an extraintestinal manifestation of any kind occurs in up to 30% of patients with IBD, and peripheral arthritis is the single most common type.
- Risk factors
Crohn disease more than ulcerative colitis: both ankylosing spondylitis and isolated sacroiliitis are roughly twice as common with Crohn disease.
- Pathophysiology
Shared enthesitis-centered mechanism: like the rest of the spondyloarthritis family, inflammation targets entheses (tendon, ligament, and joint-capsule insertions into bone), producing enthesitis…
- Clinical features
Type I peripheral arthritis: pauciarticular, fewer than 5 joints, asymmetric, typically medium to large lower-extremity joints, nonerosive, and parallels bowel disease activity; can flare with a…
- Differential diagnosis
Ankylosing spondylitis without IBD: up to 90% of White and 60% of Black patients are HLA-B27 positive, far higher than the 25% to 75% in enteropathic spondylitis or 7% to 15% in isolated…
- Diagnosis
The diagnosis is established by recognizing a spondyloarthritis-pattern joint disease, peripheral (Type I or Type II) or axial (isolated sacroiliitis or enteropathic spondylitis), in a patient with…
- Management
First, for Type I peripheral arthritis, focus on control of the underlying bowel inflammation through the standard Crohn disease or ulcerative colitis treatment algorithm; this arthritis is best…
- Complications
Unmasking of occult IBD: up to 14% of patients with established spondyloarthritis, most often ankylosing spondylitis, develop overt IBD, often from the subclinical terminal ileitis already present in up to 60%.
- Prognosis
Type I peripheral arthritis has the most favorable course, nonerosive and typically self-limited, resolving as bowel inflammation is controlled.
- Prevention
Screen for latent tuberculosis and hepatitis B before any TNF inhibitor, and avoid live vaccines during biologic therapy.
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Related articles
- Crohn disease
Crohn disease is a chronic transmural inflammatory bowel disease that can affect any segment from mouth to anus in skip lesions, most classically the terminal ileum, and is confirmed by ileocolonoscopy showing cobblestoning, skip areas, and non-caseating granulomas on biopsy. Management follows an ordered sequence of glucocorticoid or budesonide induction followed by immunomodulator or biologic maintenance, with surgery reserved for fixed complications rather than cure.
- Ulcerative colitis
Ulcerative colitis is a chronic immune-mediated disease of continuous mucosal inflammation that begins in the rectum and extends proximally through the colon, presenting with bloody diarrhea and tenesmus and confirmed by colonoscopy with biopsy. Treatment is stepped by extent and severity from 5-aminosalicylates through corticosteroids, immunomodulators, and biologics, with acute severe disease requiring IV corticosteroids and medical or surgical rescue, and colectomy remains curative.
- Ankylosing spondylitis
Ankylosing spondylitis is the radiographic axial spondyloarthritis: a chronic, HLA-B27-associated inflammatory disease of the sacroiliac joints, spine, and entheses presenting with inflammatory back pain before age 45. Sacroiliitis on pelvic radiograph or MRI establishes the diagnosis. First-line treatment is continuous scheduled NSAIDs with active exercise, escalating to a tumor necrosis factor inhibitor, then an interleukin-17 inhibitor, when NSAIDs fail.
- Reactive arthritis
Reactive arthritis is a sterile, human leukocyte antigen B27 (HLA-B27)-associated spondyloarthritis that follows a genitourinary or enteric infection by 1 to 4 weeks, producing asymmetric lower-limb oligoarthritis, enthesitis, and the urethritis-conjunctivitis-arthritis triad. It is a clinical diagnosis of a culture-negative joint. First-line treatment is an NSAID such as piroxicam for at least 2 weeks, escalating to glucocorticoids and then sulfasalazine or a tumor necrosis factor (TNF) inhibitor for disease persisting beyond 3 to 6 months.
- Psoriatic arthritis
Psoriatic arthritis (PsA) is a seronegative spondyloarthritis that develops in up to 30% of patients with psoriasis, producing asymmetric oligoarthritis or distal interphalangeal joint disease, dactylitis, enthesitis, nail dystrophy, and axial involvement. Diagnosis is clinical, supported by the CASPAR criteria. Limited peripheral disease is treated with an NSAID or intra-articular glucocorticoid, more active disease with methotrexate, a tumor necrosis factor inhibitor, or an interleukin-17 inhibitor.